Failure to Accurately Document and Maintain Resident Records
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to accurately document and maintain resident records in accordance with accepted professional standards for five residents. An audit of documentation revealed a total of 40 instances of mis-documentation related to Activities of Daily Living (ADL) over a 30-day period, with individual residents experiencing between two and sixteen occurrences each. The mis-documentation included false charting, such as documenting that baths were provided when they were not actually given. These findings were supported by a review of the facility's Employee Disciplinary Form and interviews with facility staff.